Life saver or blood sucker?

AIDS is most commonly transmitted
through sexual contact.
But the risk of being infected
with HIV through a single, HIV-infected
blood transfusion is over 90 per cent - far
higher than the risk of infection
through a single act of sexual intercourse
with an HIV-infected partner.

Medical and social scientists alike
agree that AIDS often makes a bad
situation a whole lot worse. The question
of blood safety is no exception. If
blood was always donated for purely
humanitarian reasons, and in adequate
amounts, maintaining safety and quality control would be far simpler. But unfortunately, much of the world's
blood is bought and sold like any other commodity.

The examples of blood trading described on pages 4-5 illustrate the danger of relying on
commercial
donors to meet the demand for blood.
Often the people who have to sell their
blood to survive are those most at risk
from serious communicable disease.
The need for all countries to establish
a reliable pool of regular, voluntary
and safe blood donors has never been
more urgent.

Searching for safer donors

Since the start of the AIDS pandemic,
voluntary blood donations have actually
dropped in many countries. Health
education campaigns and media stories
linking AIDS to blood transfusions
have frightened many donors, who
mistakenly believe that it is possible to
get HIV from giving blood. (This is impossible
where equipment used to collect
blood is properly sterilised.) Others
have stopped giving because they know that their blood will be tested for
HIV, and fear the result.

Discussions with potential donors in Anglophone Africa have shown that
many are worried about the blood
donation process itself; AIDS only adds
to their fear and confusion.

However, a well planned donor education campaign can substantially increase
the number of voluntary donors.

A successful donor recruitment campaign
should:

identify a target group with low HIV
seroprevalence (for example young people in school);

find out about relevant attitudes,
traditions and beliefs (e. g. through
small discussion groups);

develop educational programmes
demonstrating what the gift of blood
can offer and reassuring people
about their concerns;

treat all donors courteously.

Donor recruiters have found that strategies that work for other types of
community
education - involvement of
community leaders, peer support and
encouragement, appreciation and public recognition - are equally helpful in attracting blood donors.

Recruiters nevertheless face difficult
questions when they ask people to give
blood. Perhaps the most difficult issue
to emerge since the start of the AIDS
pandemic has been whether or not to
tell a donor that his or her blood has
tested positive for HIV. The arguments
are ethical as well as practical, as explained
on pages 6-7.

Use and abuseJust as important as the collection of
blood is its rational use. Blood transfusions are often given unnecessarily -
particularly
for anaemia. Training of
doctors and health workers on the
rational use of blood is an essential part
of any blood safety programme.

Good primary health care can reduce
the need for transfusions: health
workers should routinely check for
anaemia, and treat early. Nutritional advice
should also be given. At the
national and international level, health
and development programmes that
tackle some of the causes of severe
anaemia (such as malaria, bilharzia
and hookworm) should be
strengthened.

Clearly, global blood safety in the era
of AIDS has moved beyond the limited
technical solution of screening, although
this is obviously important. The
humanitarian motives of voluntary unpaid
donors are in sharp contrast to the
continued buying and selling of blood,
and the reluctance of some governments
to challenge the economic interests
of the blood trade.

Brave lobbying and co-operative
efforts in every country are needed to
take blood out of the market place.
Otherwise, we are merely sucking the
blood of the poor to develop unsafe
products for all.

The Zimbabwe experience

Despite increasingly high levels of sexually acquired HIV infection in the adult population, Zimbabwe's experience in
developing a national safe blood supply is an extraordinary
success story; one which illustrates not only the need for
effective management at national level, but also for
government support and political commitment.

Zimbabwe was the third country in
the world to begin routine HIV antibody testing of blood. The National Blood Transfusion Service
(NBTS) began screening in July/August 1985, and was the only centre testing clinical AIDS
cases until 1989.

The following summarises key observations made:

When donors were automatically informed of their HIV status, there was a general increase in the number of
new first time donors, suggesting some people used the Service as a testing centre. However, the number
of general donations decreased due to the fact that regular or potential donors were afraid of finding out if
they were HIV positive.

First time donors generally have a higher rate of HIV seropositivity compared to regular blood donors (a
common finding in nearly all BTSs).

New donors, in particular, who have clinical symptoms indicative of AIDS, believe the only way of confirming
their suspicions of AIDS is to have an HIV blood test. In the absence of alternative, free HIV testing sites,
they use the BTS to discover their HIV status.

Regular donors who have lapsed for more than one year also tend to be less safe and reliable and may be
using the BTS as an HIV screening service. New and lapsed donors telephone the BTS to enquire about their
results.

Regular donors are exposed to pre-donation education each time they attend and are more likely to exclude
themselves from donating if they feel their sexual behaviour and/or health status indicates their blood may not
be suitable.

Confidential, pre-donation counselling encourages the donor to self
exclude and be more willing to do so.
However, crowded rooms with lack of confidentiality mean that self exclusion
is almost impossible; any reluctance
to give blood would single
out the person not willing to donate.

A low rate of seropositivity is associated
with students and school
children (17-19 years of age).

Based on the above, the Service has
adapted its programme in two main
areas:

Blood collection Since school donations
show a low HIV seropositivity
rate, resources have been diverted into
collecting blood during term-time from
students in the 17-19 age group. This
has resulted in an increased proportion
of safe blood, and because each year
sees new students eligible for donation,
ensures a continuous source. The
younger the blood donor, the safer the
donation. During school holidays, however,
there is a general shortage of
blood; efforts to collect blood in workplaces
among regular adult donors are
stepped up.

The Service has developed health
awareness materials and a routine
health questionnaire which help the
donor to decide if their blood is free
from blood-borne diseases, including
HIV. It was found that the material was
not sufficient by itself and it is now
reinforced by the following:

pre-donation talks given during mobile
collection sessions by experts explaining who should give blood
and why. Talks focus on the tests
done and why these are necessary.
Post-test HIV counselling procedures
are discussed.

a comprehensive medical history is
taken of each donor. A nurse discusses
the routine health questionnaire
with the donor, and completes
it on the donor's behalf, ensuring a
more accurate risk assessment.

To increase blood donation countrywide,
five new collection branches
have now been opened (one in each
province). Samples from all blood collected are tested in one of two main
centres (Harare and Bulawayo).

The National Blood Transfusion
Service of Zimbabwe (NBTS) is a
non-profit organisation, with a National Committee consisting of
senior members of the Ministry of
Health, Zimbabwe Red Cross
Society and representatives of
blood donors. The committee, with
the government, is responsible for
formulating and implementing policy. All blood donations are voluntary
and non-remunerated. The Red
Cross Society assists in blood donor
recruitment and collection; since
this is part of the Service's overall
activity, standards of operation
apply equally.

Informing seropositive donors Initially, when donors were automatically
informed of their HIV status, they were
told by their respective doctors. This
policy was in operation for two years
when the prevalence of HIV in blood
donors was low. As the prevalence of
HIV rose, doctors as well as primary
health care staff could not deal with the
large numbers of people seeking counselling.
It also became evident that not
all blood donors wished to know their
results and that the donor should have
the right to choose. Accordingly, the
Service developed a system where, if
the donor wishes to know, s/he is informed
through a chosen doctor (consented
donor).

If they do not wish to know, it is
explained that BTS will not bleed them
again if any of the serology tests that
are carried out by the BTS are positive - but it is not specified which result is
positive (non-consented donor). Tests carried out include syphilis, hepatitis B
and C, and HIV. One major disadvantage is that non-consented donors,
when subsequently rejected by the
BTS, tend to assume that they are HIV
positive. To counter this, pre-donation
talks emphasise the fact that HIV is not
the only test done. Donors are given
the opportunity to change their decision.

This practice has been in operation
for one year and, to date, the only serious problem is the national shortage of
doctors and trained counsellors to provide
support for the blood donors who
test positive for any of the tests done.

Blood Programme of the League of Red Cross and Red Crescent Societies

Of the total amount of whole blood collected worldwide
every year, over one third is collected by National Red Cross
and Red Crescent Societies. Professor Robert Beal, Head of
the League's Blood Programme (LBP) in Geneva, describes
current international action on blood safety.

Blood is a priceless gift - or
should be. Without a doubt, the
quality of blood in voluntary non-profit
blood banks is higher than in any
commercial operation. The League's
Programme is based on one fundamental
principle: the recruitment of
volunteer blood donors who receive no
financial or material incentive whatsoever
for their gift, i.e. non-remunerated
donation. This principle is
promoted in the following ways:

Support to National Society blood
programmes (e. g. through technical advice). Red Cross/Red Crescent
Societies accept total responsibility for
the national blood programmes in 22
countries; in a further 37 countries, they
run collection programmes which contribute
to the national resources and, in
most of the remaining 88 countries, are
involved in donor recruitment and retention.

Assistance is provided at the request
of the National Society and may involve
in-country visits by a member of the
League's technical staff or workshops
at which representatives of National
Societies and governmental transfusion services are present. A regional
workshop held in Harare in 1990, for
example, focused on management and
leadership, and recommended (in particular)
the need for professional skills
development and career plans for
those involved in the recruitment of regular,
low-risk blood donors.

Collaboration with relevant international bodies. A particularly important
collaboration exists with the World
Health Organization. In 1988, the
Global Blood Safety Initiative (GBSI)
was formed, in which the LBP works
closely with staff within the Global Programme on AIDS and the Unit of
Laboratory and Blood Safety. This initiative also involves the International Society of Blood Transfusion, the United Nations Development
Programme
(UNDP) and some governments. Its primary objective is to
support the development of integrated
blood transfusion services in all countries.
Collaborating partners employ
consultants who, through site visits and
regional consultations, develop guidelines, manuals, and other publications.
Recent informal consultations have
dealt with autologous donation (where
an individual 'donates' blood for his/her
own future use), recruitment and retention
of voluntary non-remunerated
donors and training needs - all with a
third world emphasis.

Publication of relevant information.
GBSI consultations result in documents
published under the joint logos
of LRCRCS and WHO, which can be
accepted as the best current expertise/advice on the topic concerned. A
range of guidelines includes counselling
of HIV positive donors (back page).
Publications available from: The Blood
Programme, LRCRCS, PO Box 372,
CH-1211 Geneva 19, Switzerland.

At life's expense

The blood trade is a shocking example of how profit rarely benefits those who
work to produce the original product. People who sell their blood are precisely
those who are unable to buy it. Most commercial donors live in poor conditions,
and in poor health. They are a sector of the population whose health can least
afford regular blood loss, and who are most at risk from communicable disease.
This is not just a third world problem. This is a global, multi-million dollar
industry. The following reports reveal how the blood trade, while attracting
higher risk donors, does little to invest in quality control or essential research
into the extent of blood-borne diseases.

USA

Risk attraction

Out of 2,921 intravenous (IV) drug users
in Baltimore, USA, 793 had donated
blood at some time in their lives. 652
continued to donate after they had
started to use IV drugs. Of these, 88.1
per cent gave through the commercial
sector, and only 11.9 per cent to voluntary
blood banks. Of the total 2,921 addicts
in the study, 24.1 per cent were
found to be HIV positive. [JAMA, vol.
263,1990, pp. 2194-7].

Brazil

Breaking the blood mafia

Blood supply management in
Brazil has always been appalling,
but when the first AIDS
statistics were published the situation
caused a public outcry. One fifth of the
registered cases of AIDS in Rio de
Janeiro were the result of blood transfusions
or blood products contaminated with HIV. It was immediately
clear that infected blood was responsible
for a range of other communicable
diseases. A study carried
out in 1987 revealed that 70 per cent of
beggars in Rio de Janeiro were regular
commercial blood donors. Of this 70
per cent, seven per cent showed positive
when tested for Chagas' disease,
22.8 per cent for hepatitis, 12.9 per
cent for syphilis and seven per cent for
HIV. Around 85 per cent of haemophiliacs in the country have been infected
by contaminated blood and/or blood
products.

Brazil's blood trade relies on a complex
and secret network of blood product
suppliers, blood donors and
users. In 1988, the new Constitution
prohibited the sale of blood in Brazil,
but this law only exists on paper. At the
end of 1990, the Director of the Blood
Transfusion Service/AIDS division announced
that blood supply management
in Brazil was still not under
control. Although the Brazilian authorities
recognise the seriousness of the
problem, they still have done nothing to
deal with it. Six months on, the situation
remains unchanged.

The truth is that nobody in the country has an accurate picture of who
donates blood or how many blood
donors there are. Nobody knows how
many are voluntary and how many are
professional. This ignorance is beneficial as far as the blood trade is concerned.
Such a profitable industry has
no interest in centralising data or
supporting research into the spread of
disease. Unless Brazil's 'blood mafia'
is controlled, today's quick profit will
always be more important than tomorrow's
painful death.

INDIA

Dr Radium Bhattacharya, co-ordinator of an AIDS
training and awareness
programme in the commercial
blood sector, explains the
background to the buying
and selling of blood.

Commercial blood donors (CBDs) are mainly young males
who are pavement dwellers
(some migratory) with no fixed
address. Most are illiterate and have no
other skill to earn a livelihood, having
been in the blood trade for ten or more
years. Separated from their families,
they are likely to have more than one
sexual partner. Many of them are addicted
to tobacco and alcohol, although
in Ahmedabad none are IV drug users,
as far as we know. Our project involves
around 100 CBDs in Ahmedabad city.
These donors operate through middlemen
or agents in contact with the hospital,
clinic or pathology laboratory.

There are two types of agents: institutional agents, who act for the hospitals
attached to medical colleges, and
agents who operate for private clinics,
pathology laboratories or blood collecting
centres. Each agent has his own
group of CBDs. The agents do not own
any offices but they do have contact
telephone numbers in shops where they pay a monthly service charge.
After receiving a call from the hospital
or private clinic, the agent will contact
a blood donor in the blood group required.

Each CBD is bled more than five
times in a month, and some are donating a number of times a week. The
donors are aware that their blood
should meet certain specifications like
haemoglobin content, failing which
they may not be able to give blood or
they will be paid less. 'We take iron
tablets to keep the colour,' one donor
told us.

The lives of a great majority of India's
830 million inhabitants are dominated
by poverty, unemployment and disease.
Many are forced to sell their
blood, or even a kidney; just to survive.
Journalist and AIDS control activist
Shyamala Nataraj talked to Ashok, a professional blood donor
from Madras.

Ashok was a regular paid donor at a Bombay blood bank. Two years ago,
he was told he was HIV positive. 'I
started giving at other blood banks. If
they made a fuss, there was always
some pathology laboratory willing to
buy, no questions asked. Why should
I go out of my way to tell them? It's their job to test the blood.'
When Ashok heard of the trade in
organs, he decided to sell one of his
kidneys. This would fetch him
Rs25,000 (750 pounds sterling). A
friend took him to an agent and the
deal was fixed. 'They did many tests
on me to see if my kidney matched but
obviously didn't do the HIV one. I got
caught only because another donor
told the doctor.'

Ashok's story clearly illustrates the
need not only for adequate HIV counselling,
but also for alternative income -
generating opportunities for
commercial donors found to be carrying
any dangerous blood-borne disease.

'AIDS has reached India'

In January 1989, daily newspapers
carried headlines announcing that
HIV antibodies had been discovered
in blood products manufactured in
India. The truth had finally hit home:
'AIDS has reached India, and no-one
is safe from it' [Indian Express].
By the end of February 1991,
820,400 people had been screened
throughout the country for the presence
of HIV antibodies. Of these,
4,778 were found to be positive
(confirmed by Western Blot) giving a
rate of 5.82 per thousand.

Heterosexual transmission accounted
for just over half of these.
Blood donors accounted for 17 per
cent of the total number, only slightly
lower than intravenous drug users at
23.2 per cent. In Maharashtra alone
the percentage of infected blood
donors (27.3 per cent) was higher
than that of infected sex workers
(27.1 per cent).

India's most immediate problem is
that it cannot afford to eliminate
commercial blood donation overnight,
since this provides up to 50
percent of all transfused blood in the
large cities.

Commonsense and sensitivity

The Medical Mission Institute based in Germany has
considerable experience in providing assistance to developing
countries in AIDS prevention and control. This includes the
introduction of HIV testing kits to rural hospitals in eleven
African countries, India and Papua New Guinea. Staff at the
Institute provide an overview of the key ethical and practical
issues involved.

AIDS is the final stage of infection
with HIV. But this infection is, difficult to recognise; it can take
many years before an infected individual develops any signs or symptoms
of HIV disease/AIDS. In the
meantime the virus may be passed on
to others unknowingly - through donating
infected blood, or (more commonly)
through sexual transmission and from a mother to her unborn child.
It is therefore understandable that so
much importance is attached to the test
for HIV.

But what do HIV tests tell us? Most
tests do not detect the virus itself, since
this is a very complicated, expensive
procedure. Tests commonly used detect the virus only indirectly, by demonstrating
the presence of antibodies to
the virus produced by the immune system(1). However, after initial infection
with HIV, it takes some time for antibodies
to be produced and to be detectable - usually a few weeks, but
sometimes a few months or even
years. During this period (known as the
'window period') the HIV antibody test
will be negative, even though an infected
person's blood, sperm or vaginal
fluid are infectious to others.

This means that a single test cannot
indicate for sure whether an individual,
or a unit of donated blood, is free of the
virus or not. This causes problems, not
only in the misleading use of tests used
by individuals to declare they are 'AIDS free',
but also for ensuring a totally safe
blood supply. The window period
means that blood must be donated
from sectors of the adult population
who are considered a lower risk from
HIV.

A question of accuracy
The quality of a test is determined by
its sensitivity and specificity. Sensitivity
describes the probability (expressed
as a percentage) that the test result will
be positive when antibodies to HIV are
present. Specificity describes the probability
(as a percentage) that the test
result will be negative if antibodies to
HIV are not present. An ideal test would
be 100 per cent sensitive (always positive if HIV antibodies are present) and
100 per cent specific (never positive if
they are not present). But no test is
ideal.

HIV antibody tests are divided into
two groups:

screening (ELISA, membrane capture assays, agglutination tests). These are used for blood transfusion
purposes and should have a high
sensitivity to 'net' all possibly infected
samples, which usually
means that some un infected
samples are also 'caught'. A single
positive test result does not necessarily mean that the tested person is
infected.

confirmatory (Western Blot, Immunoflourescence,
Radioimmuno-precipitation
assay). These should have an especially high specificity.
They are used to find out which of the
samples 'caught' by the screening
test should really be considered as
infected. Even these tests do not
give 100 per cent assurance of a
person's sero-status (whether they are HIV positive or negative).

'Testing for HIV does have a
role to play in AIDS control
programmes, but it can
cause more harm than good
if the implications are not fully understood. '

Prevention or persecution?
Depending on the reason for carrying
out the test in the first place, a tested
individual mayor may not be told if their
HIV antibody test is positive (see next page). However, the following principle
should ideally apply: at least one positive screening and one positive
confirmatory
test are needed before a result
is made known to the individual concerned.

It is a commonly held view that if a
person is told their HIV antibody positive result, s/he will ensure that the
spread of the virus to others is prevented.
This principally means changing their sexual behaviour. However,
little is known about how and why
people are motivated to change their
most intimate behaviour, but knowledge,
emotional well-being and respect
for others are surely
fundamental. All too often, however,
infected individuals must endure all the
negative consequences of knowing their positive result, and none of the benefits, such as psychosocial
assistance,
early diagnosis, prevention and treatment of opportunistic infections,
and (although experimental) anti-viral regimes. First they may be
told this devastating news in a seemingly
insensitive way by an overworked
health professional. Once labelled 'HIV
positive', these people then face social
isolation and discrimination.

Even where the test is negative, testing for HIV without proper counselling
can actually promote the spread of the
virus. People with a negative test result
may well develop a false sense of
security which can tempt them into continuing
with risk behaviour...until the
test turns out positive.

When, why and whom to test

In all test situations confidentiality is of
the highest priority.

Testing of individuals This should
only be done with proper informed consent,
where the individual has fully considered
the implications of receiving
both a negative and al positive result
(voluntary testing).

The reason for testing, and being told
the result, should be carefully considered.
Many people may be in personal
and/or economic situations in
which they cannot change their risky
behaviour, regardless of the result.

Testing on the request of a third party (governments, religious
institutions, schools, employers) is both ethically and practically very
questionable. Stated reasons such as 'We don't want to invest in a
scholarship for someone who is going to die' reflect a prejudice and lack of
understanding about the test and the nature of the infection. A negative
test does not necessarily mean that the individual won't become infected
some time in the future. Even if the individual is infected, they may remain
healthy for many years - plenty of time to have a productive input into a
company. If the individual, after pre-test counselling, still wants to be
tested, the result should never be given to the third party without written
consent (given after the results) of the tested individual.

Where HIV testing is carried out to support a clinical diagnosis of HIV
disease/AIDS, individuals should only be asked to undergo a test if the
result will help in deciding on the best course of medical care.

Testing population sectors for
epidemiological surveys This can
only be done with the approval of qualified
authorities. Surveys conducted
without the informed consent of the
individuals tested must ensure that the
results are not given to the person
whose blood was screened and that
their name is not linked to the results
(known as anonymous testing).

Screening of donated blood
Donors should ideally be screened
before actually testing for HIV antibodies by identifying any past high-risk
behaviour, taking a medical history and
conducting a medical examination (i.e.
blood from donors with a history or
signs of a sexually transmitted disease
should be excluded).

All units of blood which test HIV antibody
positive must be destroyed.
Where informed consent has not been
given, and/or proper counselling can-not
be provided, and/or confirmatory
testing cannot be done (since this is
expensive) the screening results
should not be disclosed to the donor
concerned (see Zimbabwe experience,
pages 2-3).

The principal aim of testing blood
samples is to render blood transfusions
safer, not to find seropositive individuals.

Which screening test to use?

For rural hospitals in poor countries,
where blood cannot be stored but is
often needed in emergency situations,
a test is needed which does not require
additional equipment, is highly sensitive and specific, easy to perform in a
short time and can be used economically on small numbers of blood
samples. Under these conditions we
recommend HIV Chek (see AIDS action
issue 5), which is now distributed
by Ortho Diagnostics(2).

However, the price of HIV Chek is still
far too high for most developing countries
and serious delays have been experienced
in supply and delivery.

In summary, testing kits should not
be supplied to anyone without sufficient
written guidelines on ethical as well as
practical indications for their use. A personal
introduction to the benefits and
limits of testing by a trained professional
is crucial.

1 For further information on HIV testing
and tests see AIDS action issue 3.

2 Another low-cost screening test,
PATH HIV Dipstick, has been
developed for manufacture and use in
developing countries, by the Program
for Appropriate Technology in Health
(PATH), with support from the International
Development Research
Centre of Canada, and the Rockefeller
Foundation. Contact: PATH, 4 Nickerson
St., Seattle, Washington State
98109-1699, USA. - Ed.

Letters

No support in Tanzania?In Tanzania people with AIDS (PWAs)
have no support. They are cared for by
parents and relatives who are often
very poor and live in rural areas. Why
has Tanzania not formed an AIDS related
non-government organisation? Such an organisation I could provide
support - especially in remote areas
or where PWAs have no support.

A Nsyenga, Ileje, Mbeya, Tanzania.

Ed: There are some local projects that
could offer support for people with HIV
infection and AIDS. Both the Catholic
Church (c/o Catholic Secretariat, P 0
Box 2133, Dar es Salaam) and the
Evangelical Lutheran Church (c/o
ELCT Medical Board, P O Box 3033, Arusha) have AIDS control programmes
with activities at the diocesan
level. AMREF (PO Box 2772, Dar es Salaam) runs an AIDS Health Services
Support Project. There is also a regional
AIDS information centre based
at the Centre for Educational Development
in Health (P O Box 1162, Arusha).

Screening blood donors A reader writes from Africa: screening
of donated blood has recently been
introduced here in a small town hospital.
Technicians from all parts of the
country including ours were given a
one day training course at the main
hospital in the capital city, given supplies
of Dupont test kits and have now
gone back to their hospitals. I am concerned
that the social aspects of testing
were not covered in the training. For
example, in small towns like ours,
those carrying out the tests to screen
donated blood or who have access to
the results may well know the donors
and there may be a danger that those
who are HIV positive will be identified.
I would be grateful if AIDS Action could
give advice about setting up procedures for screening blood, including
ensuring confidentiality and how to
deal with those who are positive.

Ed: We hope this special issue pro-vides
some of the information you
need.

Never too young... I am a 16 year old who reads the copies
of AIDS Action which you send to my
mother. I was astonished to read in
issue 11 about children living on the
streets and some starting prostitution
as young as eight years old, and particularly
about the fifteen year old boy
who had been imprisoned four times
and hospitalised twice.

Veronica, Bo, Sierra Leone.

Resources

AIDS Orphans in Tanzania;
Care and Prevention in Ghana
Strategies for HopeThis series of booklets describes
pioneering experiences in AIDS care
and prevention in several African countries.
The latest editions, 4 and 5, look
at AIDS care and prevention in Ghana,
and AIDS orphans in Tanzania. Each
contains practical examples of activities
carried out by all sectors of society.
Published by ActionAid, AMREF, and
World in Need. 300 pages, price £1.50.
Available from: TALC, P 0 Box 49, St
Albans, Herts AL1 4AX, UK.

Guidelines for the
Appropriate Use of BloodPart of a series of documents produced
by the Global Blood Safety Initiative
(see page 3). Aimed at health workers
involved in minimising the use of blood
transfusions - an essential part of
blood safety programmes.Free of
charge from: GBSI, WHO, 1211
Geneva 27, Switzerland.

'The life you save'
Sixteen minute video developed for
African populations. Designed for use
by blood donor programme officers to
aid discussion in educational campaigns
aimed at encouraging recruitment
of regular, committed blood
donors who are well informed about
HIV and the risks of transmission to
patients via infected donations.
Developed by the Zimbabwean Red
Cross in consultation with the Blood
Programme of the League of Red
Cross and Red Crescent Societies (LRCRCS) in Geneva. Funded by
WHO.
Available in English from: The
Blood Programme, LRCRCS, PO
Box 372, CH-1211, Geneva, Switzerland.

Seropositive donors
Informing a donor who has tested HIV
positive requires special skills and
must be done in a sensitive way.
LRCRCS and the WHO Global Programme
on AIDS are examining ways
of increasing counselling and support
services for HIV positive donors, and
the role of blood transfusion services in
post-test counselling. Guidelines available
by the end of 1991. Other useful
publications, including the regular
newsletter Transfusion International
available from the address
above.

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